974

Occasional Book

COMPREHENSIVE MEDICINEIN the coming years medical care, education, and research

are likely to become even more satisfying, demanding, andsocially involved than they are now. New knowledge willout, even if societies are slow to apply it. But there willbe a few constants at work, and one of these will be the almostuniversal desire for harmony between the technical and per-sonal elements in medical care. Even the supertechnologistsof medicine have to admit (especially when they are ill them-selves) that no man is an island. The term " comprehensivemedicine " was coined to connote a system and a practicewhich embodies simultaneous recognition of the biology,psychology, and sociology of illness, at both individual and

population levels. A new book spells out the nature ofcomprehensive medical care and how it has been taught tosenior medical students, and also attempts to evaluate theresults of its practice.

This substantial project originated in 1950 from a feeling ofdissatisfaction among physicians and teachers with the out-patient services of the New York Hospital and with theireducational use by the Cornell Medical College. Fragmen-tation of care, little or no clinical responsibility for students,poor continuity of patient supervision, and inadequate linkswith the community were all recognised, and led to thedecision to change the system in the interests of patients andstudents. The Commonwealth Fund backed the enterprise,and since 1951 the comprehensive care and teaching pro-gramme (c.c. and T.P.) has been in operation. Its chief aimwas:

" to create an environment where patients could receive systematicand thorough evaluation of their needs, continuity of care with onephysician, and completeness in the management of all their problems.Continuity of care would be accomplished by assigning one studentphysician and an instructor to each patient. This student physicianwould co-ordinate all services available and necessary for the patientand act as liaison between the patient and whatever consultantsmight be required; he would thus be in a position to learn all aboutthe problems confronting the patient and the attempts at solution."

A rearranged final-year curriculum and an expanded staffof clinical teachers enabled students to spend some twentyweeks in the general medical, paediatric, and psychiatric out-patient clinics where, under supervision, they acceptedresponsibility for "

complete, continuous, co-ordinated and

compassionate "

care of patients. Clinical, personal, and socialassessment and management, including home care whereindicated, were primarily assigned to the students, who hadaccess to all the hospital’s facilities and to a designated super-visor. The results of this new emphasis upon student responsi-bility were expected to show mainly in attitudes and values,the aim being to encourage a quicker development of " themature outlook of the practitioner and some wisdom andclinical judgment".Did the programme achieve its objectives ? From an

elaborate study of the first few years the answer seems to be aqualified " yes ". Students did become more concerned withthe patient as a whole person, attached greater importance tosocial and emotional problems, and appeared to develop self-confidence in coping with clinical conditions. But there wassome evidence that these gains did not persist much beyondthe period of the programme, and the authors feel obliged toremark that " the medical student may be looked upon inthis respect as a highly adaptive being who takes on, like thechameleon, the colouration of the environment in which hefinds himself". To those who feel disappointed at the lackof clear-cut results (and perhaps to those who feel the oppo-site) two points can be made : first, measurement of subtle

1. Comprehensive Medical Care and Teaching: a report on the NewYork Hospital—Cornell Medical Center Program. By GEORGE G.READER, M.D. and MARY E. W. Goss, PH.D., assisted by BARBARAKORSCH, M.D. New York: Cornell University Press. 1967. Pp. 391.S11.00.

changes in attitudes is not easy; and, second, there may be aconsiderable lag period before lasting changes in behaviourappear.

Whilst the measurable return from this huge experimentalinvestment may seem small, the c.c. and T.P. forced allinvolved to think afresh about aims and methods; it stimu-lated interest in research and evaluation; it brought togetherrelated professional disciplines which have much to giveeach other. Furthermore this book offers much to readers inthe United Kingdom. This country has sometimes beenaccused of reluctance to check on the value of change; andbooks like Comprehensive Medical’Care and Teaching show howinseparable change and check really are.

Parliament

Hearing-aids BillON April 26 Mr. LAURENCE PAVITT’S Hearing-aids Bill

passed its second reading. The Bill provides for setting up ahearing-aids council to register manufacturers and suppliers ofhearing-aids, advise on their training, and regulate trade

practices.QUESTION TIME

Prescription ChargesAn agreement has now been reached between the Minister

of Health and the professions on the interim arrangements forexemptions from prescription charges for England and Wales.Discussions are continuing with the Scottish chemists. Patientswho are entitled to exemption on age grounds will completea declaration on the back of the prescription form. Thechemist will then not levy a charge. Expectant and nursingmothers, persons with conditions needing continuous medi-cation,l and people receiving supplementary benefits and thoseliving below or at that level 2 will be given exemption certi-ficates. Arrangements will also be made for charges to berefunded where necessary, but the wide scope of exemptionswill mean that this will be necessary in only a few cases.These arrangements will come into effect on June 10.

Licences to Prescribe Dangerous DrugsUnder the Dangerous Drugs (Supply to Addicts) Regula-

tions 1968, licences to prescribe heroin and cocaine to addictshave been issued to 545 doctors, of whom 529 are on the staff of219 National Health Service hospitals in Great Britain wheretreatment is provided. Licences have been granted to 7 doctorsin the Prison Service in England and to 9 doctors on the staffs ofthree non-National Health Service establishments wheretreatment is provided.

Beds for the Younger Chronic SickIn April last year 4223 younger chronic sick were in National

Health Service hospitals and contractual beds, and 664 were onwaiting-lists.

Prohibition of Chemical and Biological WarfareThe following countries have become parties, either by signa-

ture and ratification, or by accession, to the Geneva Protocol of1925, under which they accepted the prohibition of the use inwar of asphyxiating, poisonous, or other gases, and of all analo-gous liquids, materials, or devices, and agreed to extend thisprohibition to the use of bacteriological methods of warfare:

Australia, Austria, Belgium, Bulgaria, Canada, Ceylon, Chile,Chinese People’s Republic, Cuba, Cyprus, Czechoslovakia, Den-mark, (Estonia), Ethiopia, Finland, France, Gambia, Federal Republicof Germany, Ghana, Greece, Hungary, India, Iran, Iraq, IrishRepublic, Italy, (Latvia), Liberia, (Lithuania), Luxembourg, Mala-gasy Republic, Maldive Islands, Mexico, Monaco, Netherlands, NewZealand, Norway, Pakistan, Paraguay, Poland, Portugal, Rumania,Rwanda, Sierra Leone, South Africa, Spain, Sweden, Switzerland,Tanganyika, Thailand, Tunisia, Turkey, Uganda, U.S.S.R., UnitedArab Republic, United Kingdom, Vatican, Venezuela, Yugoslavia.

1. See Lancet, March 30, 1968, p. 702.2. See ibid. April 20, 1968, p. 857.